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05/07/2018

BioethicsTV (April 30 – May 4): #TheResident; #ChicagoMed

by Craig Klugman, Ph.D.

The Resident (Season 1; Episode 12): Pressures of the Medical Life; Making promises; Chicago Med (Season 3; Episode 18): Crisis response

The Resident (Season 1; Episode 12): Pressures of the Medical Life; Making promises

When Bradley, a resident, falls through a glass ceiling and crashes onto the board room table, Bell’s first reaction is that neither the hospital nor he are responsible for the epidemic of suicides in medicine. Rather than trying to find a solution to the problem or even trying to find out what happened, Bell is trying to be sure he has a chair when the music stops. The rate of suicide in residents has been increasing, from 2000-2014, 0.017% of residents committed suicide (66 out of 381,614 residents). With a metal bar impaled through his chest—and missing major organs, Okafor is taking Bradley to surgery when his parents come up to her and ask her to promise that he will be okay. Okafor says “Surgeons don’t make promises.” Since doctors should not make promises they cannot keep, this is the appropriate response. However, she then said “In this case, I’ll make an exception” which is the wrong thing to say, especially with a severely injured patient.

The residents figure out that Bradley had a heart condition and his use of stimulants and high caffeine drinks caused him to pass out. After he awakens after surgery, Bradley admits he’s had thoughts of ending of his life and of walking away from the pressured life of being a doctor. Admitting that medicine is not the life for him after going through medical school, part of residency, and being under pressure from his parents is not easy, but it also probably more common than we know.

Chicago Med (Season 3; Episode 18): Crisis response

When a mass gun shooting occurs, the ED is quickly inundated with victims. A woman is brought to a bed; she has massive bleeding and the doctor is performing CPR. Goodwin and Stohl stop the care, saying “Treatment is for the living; Mass casualty protocols—no CPR.” Every hospital in the city is likewise inundated with the injured. This episode is about triage, moving from everyday levels of care and decision-making to crisis protocols, where the goal is to save as many people as possible. This requires making people who are dead or likely to die comfortable, seeing the walking wounded last (though keeping an eye on them in case they get worse), and treating first those people who are seriously injured with a high likelihood of surviving with available resources. Every hospital has a mass casualty plan in place and they can differ a bit. Most large cities, counties, and states also have plans for incidents that cover large numbers of people. These larger plans can include mobilizing state and federal stockpiles of medical supplies, establishing treatment areas in schools or outdoors in tents, and even bringing in the national guard.

Choi suggests making care more efficient by not only “tagging” patients (black, red, yellow, green denoting priority of treatment) but also by placing people with similar injuries and needs geographically near each other—sort of an assembly line for medical care. This way specialty teams can move quickly from one patient to another without having to track patients down across the entire ED, waiting rooms, and hallways. Staff are called in from home whether they are on call or not. What become clear very quickly is that they are improvising. When Stohl tells Goodwin that he is not comfortable with making it up as they go along, she responds that their casualty plan never foresaw anything like this. Improvising is the only option. The break room becomes a morgue; the less injured are taught how to dress bandages and stop bleeding so they can help those with more injuries. In the Texas plan, doctors can come from out of state and work without a license during such an emergency. In other states, medical and nursing students can be recruited to provide some care, since they have more exposure, knowledge and training than a lay person. When they run out of ventilators, Halstead says they have to go to handbagging. Manning points out that they don’t have enough staff. He says they’ll put two people on each vent which is not ideal but might work for a while. In reality, these are all ideas that have been made part of various casualty plans. Regarding the shortage of vents, many plans call for withdrawing vents from those less likely to benefit to help those who are more likely: That might require withdrawing a vent from someone currently on one to treat a newer patient. However, Halstead’s solution gets around an interesting legal concern in Illinois–even in a mass casualty situation, removing a patient from a vent, without patient or surrogate consent or death, is not protected and could elicit a murder charge. Those of us working on the state’s crisis response plan are engaging with legislators to change that.

In a dramatic storyline, the shooter crashes and needs help. Psychiatry hides his identity so that he can get the care that any human in that condition needs. But when his identity becomes known, the staff feels tricked and that they should not have helped him. At the end, Goodwin says that treating the shooter was the right thing because all people in need are patients and all patients deserve care and compassion, not judgement.

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